Nursing homes throughout Virginia are struggling to meet minimum quality standards, but a measure intended to help solve the problem was shot down by state lawmakers last week.
A House panel voted to delay taking action on House Bill 646, a proposal that would introduce minimum staffing requirements for the Commonwealth’s nursing homes. Now, the bill won't be up for review again until at least 2023.
The news came as a blow to advocates who expected that the fallout from the Covid-19 pandemic - which has led to more than 4,770 deaths in Virginia nursing homes - might finally bring much-needed change. Experts say facilities with low staffing were more likely to experience severe Covid-19 outbreaks.
Legislators have declined to support efforts to raise workforce standards at the state’s long-term care facilities for the past 18 years in a row.
“We are profoundly disappointed that the subcommittee postponed acting on the concerns of the hundreds of people who have called and emailed their legislators in support of this measure," said AARP advocacy director Natalie Snider in response to the decision by the House Health, Welfare and Institutions Subcommittee to postpone action on the bill.
HB 646 would have required long-term care facilities in the state to abide by minimum hourly staffing standards in a bid to ensure that patients receive sufficient care. Nursing homes would be expected to provide a minimum of 4.1 hours of direct care per resident per day from nurses and Certified Nursing Assistants (CNAs). At least 45 minutes of that care per day would need to be provided by a registered nurse (RN).
After years of stalled progress on efforts to establish staffing standards, Virginia AARP and other advocacy groups had settled on a compromise that would have phased in minimum staffing standards over a period of 8 years. But even that proposed solution wasn't embraced by lawmakers.
"The continued failure of the General Assembly to help Virginia’s most vulnerable residents and their families is even more discouraging because they rejected an opportunity at compromise that would have brought the state closer to enacting a common-sense solution overwhelmingly supported by voters in the state," Snider said.
The findings, based on a thorough, year-long analysis, revealed that 43% of the state's nursing homes "received a 1- or 2-star Staffing rating from the Centers for Medicare and Medicaid Services (CMS), indicating inadequate staffing." By comparison, the nationwide average for 1- or 2- star Staffing ratings is just 31%.
CMS, a federal U.S Health Department agency, uses a Five-Star Quality Rating System that's based on staffing, quality measures and health inspection findings. A score of 1 or 2 stars typically means the facility is performing below average and must improve.
Also alarming is the fact that over 100 nursing homes in Virginia are currently on a national watch list for causing patient harm. Several of those facilities are located on the Peninsula.
The Joint Commission on Healthcare's analysis emphasized that staffing shortages at Virginia's long-term care facilities are disproportionately impacting families with low incomes as well as Black residents. Nursing homes with higher percentages of Medicaid residents also tended to have poorer health inspections and lower quality ratings.
"Fewer older Black adults have private insurance than white adults and are more likely to be reliant on Medicaid. Nationwide, Black nursing home residents are much more likely to be in nursing homes where the majority of residents are supported by Medicaid," the Commission said.
Of the facilities with low staffing levels in Virginia, the majority - over 60 percent - received poor health inspection ratings, according to the report.
Additionally, more than half of all complaints logged with the Virginia Office of the State Long-Term Care Ombudsman are consistently related to insufficient staffing. Families routinely report slow response times, a lack of assistance with daily care needs and even gross neglect.
The Commission ultimately concluded that the introduction of staffing minimums would likely mitigate many of these concerns.
“Increasing the number of hours of direct care per resident is shown to improve clinical outcomes and resident satisfaction,” the report states.
After losing loved ones in tragic nursing home incidents, three Virginians founded a group, Justice and Change for Victims of Nursing Facilities, to advocate for policy changes. The group recently conducted a campaign to push for HB 646, with many submitting letters to legislators detailing stories of abuse and neglect. But the pleas seemed to fall on deaf ears.
"I've been on this journey now for almost 3 years... and I have a diary that is hundreds of pages," said group member Robin Wertz Craig while urging others to continue fighting for change.
Snider echoed a similar sense of determination, saying that people in nursing homes are often incapable of advocating for themselves and depend on others to help give them a voice.
"The facilities owe a duty of care to nursing home residents and their families, as well as accountability to the taxpayers of the Commonwealth of Virginia, which provides the facilities with billions of dollars from the state Medicaid program," she said.
Nursing home industry lobby groups - including the Virginia Health Care Association and the American Health Care Association - have been pushing back against the concept of staffing minimums for years, saying the requirements would further exacerbate staffing shortages.
“The workforce simply isn’t there,” Amy Hewett, vice president of strategy and communications for VHCA, said in a February 8 interview with Skilled Nursing News. “We have been able to look at data from the Bureau of Labor Statistics that shows over the past pretty lengthy period of time, nursing home and residential care staffing was increasing in Virginia, and then when the pandemic hit, the floor dropped out of our workforce.”
According to the Bureau of Labor Statistics, Virginia's long-term care facility workforce has lost over 9,500 employees since Covid-19 broke out in 2020. That figure is reflective of the national situation: across the U.S, about 14% of all skilled nursing employees left their jobs during the pandemic.
The Joint Commission on Health Care acknowledged in its report that Covid has played a significant role in worsening existing workforce shortages in the state's nursing homes, noting that there are "a decreasing number of (LPNs) and CNAs in Virginia" and that recruitment in the industry "can be difficult." However, the findings also showed that retention efforts are generally much more successful when wages, benefits, training and advancement opportunities are improved.
Advocates also point out that staffing standards are the norm for nursing homes throughout the U.S, even though recruitment and retention problems remain a nationwide struggle. Virginia is one of only 16 states in the country that hasn’t implemented a nursing home staff requirement.
Some recent developments have indicated that changes on the federal level may have some impact on nursing homes in the state.
In January, the Office of Inspector General for the U.S Department of Health and Human Services released findings suggesting that additional oversight of nursing homes - and the initiation of more meaningful intervention – appears necessary.
Meanwhile, although state lawmakers declined to institute a workforce minimum for long-term care facilities again this year, Ginger Thompson, a Williamsburg resident and communications manager for AARP Virginia, said people can still take several key actions to advocate for their loved ones in nursing homes.
"My mother is in a nursing home, and I advise that families visit often and be observant," Thompson said.
"Communicate regularly with the management staff, and get to know the staff that are providing the hands-on care, especially the CNAs. Make sure you attend (either in-person or virtually) all quarterly care plan meetings, and make sure you voice your concerns and ask questions about your loved one’s care. Alert management if you notice a problem, and if your concerns aren’t addressed, contact your local long-term care ombudsman."
Snider also said that while many families have expressed concerns over the state’s failure to address nursing home quality concerns, now is not the time to give up on efforts to push for meaningful legislative action.
“Advocates have been fighting for appropriate staffing levels in nursing homes for two decades. We aren’t going away, and lawmakers will be hearing even more from us, our members, and the public in the future," she said.
People with loved ones in Virginia nursing homes can locate their local ombudsman here.
This podcast by The National Consumer Voice for Quality Long-Term Care also provides guidance for preventing and getting help for nursing home neglect situations.
Medicare.gov offers a comparison tool to help people sort through health inspection, staffing and other ratings data at nursing homes.
The NHAA watch list flags nursing facilities with serious quality issues, unsafe staffing levels, very low-quality ratings or a history of causing harm.
The Centers for Medicare and Medicaid Services also maintains a list of facilities with serious deficiencies.